Provider Demographics
NPI:1487202313
Name:FUENTES HERNANDEZ, CELIMAR
Entity Type:Individual
Prefix:
First Name:CELIMAR
Middle Name:
Last Name:FUENTES HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MONTECASINO HTS
Mailing Address - Street 2:100 CALLE RIO JAJOME
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:787-371-8413
Mailing Address - Fax:
Practice Address - Street 1:MONTECASINO HTS
Practice Address - Street 2:100 CALLE RIO JAJOME
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-371-8413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR003431183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
8570122OtherCASA MAMI